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An inaccurate medical record can bring a great risk of harm to any patient. It is part of the nurse’s duty to ensure that the patient has the correct records. But if an RN incorrectly documented on the patient’s chart there’s a corresponding consequence to it. The Board may summon you and subject you to disciplinary action or even worse than that. But a nurse attorney on the other hand can help you get through such a situation.

At the time of the initial incident, an RN was employed as a Registered Nurse at a hospital in Grand Prairie, Texas, and had been in that position for four (4) months.

It was on or about December 23, 2018, an RN inaccurately documented in the chart of the patient that the patient was both alerts and oriented x 4 but also disoriented to place, time, and location. The RN’s conduct created an inaccurate medical record and was likely to injure the patient in that subsequent caregivers would rely on her documentation to provide further patient care.

In response, the RN states that she meant to document that the patient was disoriented to place, time, and situation, and admits it was a documentation mistake that she incorrectly documented oriented x4. She states that she did revise it according to her bedside assessment which was disoriented to place, time and situation. However, she wasn’t able to change or unclick the alert and oriented X4 on the dropdown menu because while doing so she received another call from another patient that needed her help, and as a result, she saved the GCS information and planned to come back to redo it as soon as she was finished with the patient who called her. She states that she did not recall that she needed to review and change her documentation, and admits that was an error on her part. The RN states that no harm came to the patient as a result of this.

Because of the incident, the Texas Board of Nursing has subjected the RN to disciplinary action. It is proved that the RN has committed violations. Avoid a similar thing from happening on your end. Make sure to find the right nurse attorney in case a complaint will be filed against you before the Texas Board of Nursing (BON).

Consult with Texas nurse attorney Yong J. An today if you have any questions about your disciplinary process by calling or texting him at (832) 428-5679 day, night or weekends.